Patients that survive hemorrhage and resuscitation (H/R) may develop a systemic inflammatory response syndrome (SIRS) that leads to dysfunction of vital organs (multiple organ dysfunction syndrome, MODS). SIRS and MODS m...Patients that survive hemorrhage and resuscitation (H/R) may develop a systemic inflammatory response syndrome (SIRS) that leads to dysfunction of vital organs (multiple organ dysfunction syndrome, MODS). SIRS and MODS may involve mitochondrial dysfunction. Under pentobarbital anesthesia, C57BL6 mice were hemorrhaged to 30 mm Hg for 3 h and then resuscitated with shed blood plus half the volume of lactated Ringer's solution containing minocycline, tetracycline (both 10 mg/kg body weight) or vehicle. Serum alanine aminotransferase (ALT), necrosis, apoptosis and oxidative stress were assessed 6 h after resuscitation. Mitochondrial polarization was assessed by intravital microscopy. After H/R with vehicle or tetracycline, ALT increased to 4538 U/L and 3999 U/L, respectively, which minocycline decreased to 1763 U/L (P < 0.01). Necrosis and TUNEL also decreased from 24.5% and 17.7 cells/field, respectively, after vehicle to 8.3% and 8.7 cells/field after minocycline. Tetracycline failed to decrease necrosis (23.3%) but decreased apoptosis to 9 cells/field (P < 0.05). Minocycline and tetracycline also decreased caspase-3 activity in liver homogenates. Minocycline but not tetracycline decreased lipid peroxidation after resuscitation by 70% (P < 0.05). Intravital microscopy showed that minocycline preserved mitochondrial polarization after H/R (P < 0.05). In conclusion, minocycline decreases liver injury and oxidative stress after H/R by preventing mitochondrial dysfunction.
Liver ischemia/reperfusion (IR) injury is caused by a heavily toothed network of interactions of cells of the immune system, cytokine production, and reduced microcirculatory blood flow in the liver. These complex networ...Liver ischemia/reperfusion (IR) injury is caused by a heavily toothed network of interactions of cells of the immune system, cytokine production, and reduced microcirculatory blood flow in the liver. These complex networks are further elaborated by multiple intracellular pathways activated by cytokines, chemokines, and danger-associated molecular patterns. Furthermore, intracellular ionic disturbances and especially mitochondrial disorders play an important role leading to apoptosis and necrosis of hepatocytes in IR injury. Overall, enhanced production of reactive oxygen species, found very early in IR injury, plays an important role in liver tissue damage at several points within these complex networks. Many contributors to IR injury are only incompletely understood so far. This paper tempts to give an overview of the different mechanisms involved in the formation of IR injury. Only by further elucidation of these complex mechanisms IR injury can be understood and possible therapeutic strategies can be improved or be developed.
Background. Hazards of liver surgery have been attenuated by the evolution in methods of hepatic vascular control and the anesthetic management. In this paper, the anesthetic considerations during hepatic vascular occlus...Background. Hazards of liver surgery have been attenuated by the evolution in methods of hepatic vascular control and the anesthetic management. In this paper, the anesthetic considerations during hepatic vascular occlusion techniques were reviewed. Methods. A Medline literature search using the terms "anesthetic," "anesthesia," "liver," "hepatectomy," "inflow," "outflow occlusion," "Pringle," "hemodynamic," "air embolism," "blood loss," "transfusion," "ischemia-reperfusion," "preconditioning," was performed. Results. Task-orientated anesthetic management, according to the performed method of hepatic vascular occlusion, ameliorates the surgical outcome and improves the morbidity and mortality rates, following liver surgery. Conclusions. Hepatic vascular occlusion techniques share common anesthetic considerations in terms of preoperative assessment, monitoring, induction, and maintenance of anesthesia. On the other hand, the hemodynamic management, the prevention of vascular air embolism, blood transfusion, and liver injury are plausible when the anesthetic plan is scheduled according to the method of hepatic vascular occlusion performed.
Pulmonary complications after liver transplantation (LT) often cause mortality. This study investigated whether small-for-size LT increases acute pulmonary injury and whether NIM811 which improves small-for-size liver gr...Pulmonary complications after liver transplantation (LT) often cause mortality. This study investigated whether small-for-size LT increases acute pulmonary injury and whether NIM811 which improves small-for-size liver graft survival attenuates LT-associated lung injury. Rat livers were reduced to 50% of original size, stored in UW-solution with and without NIM811 (5 μM) for 6 h, and implanted into recipients of the same or about twice the donor weight, resulting in half-size (HSG) and quarter-size grafts (QSG), respectively. Liver injury increased and regeneration was suppressed after QSG transplantation as expected. NIM811 blunted these alterations >75%. Pulmonary histological alterations were minimal at 5-18 h after LT. At 38 h, neutrophils and monocytes/macrophage infiltration, alveolar space exudation, alveolar septal thickening, oxidative/nitrosative protein adduct formation, and alveolar epithelial cell/capillary endothelial apoptosis became overt in the lungs of QSG recipients, but these alterations were mild in full-size and HSG recipients. Liver pretreatment with NIM811 markedly decreased pulmonary injury in QSG recipients. Hepatic TNFα and IL-1β mRNAs and pulmonary ICAM-1 expression were markedly higher after QSG transplantation, which were all decreased by NIM811. Together, dysfunctional small-for-size grafts produce toxic cytokines, leading to lung inflammation and injury. NIM811 decreased toxic cytokine formation, thus attenuating pulmonary injury after small-for-size LT.
Bile leaks from the intrahepatic biliary tree are an important cause of morbidity following hepatic surgery and trauma. Despite reduction in mortality for hepatic surgery in the last 2 decades, bile leaks rates have not...Bile leaks from the intrahepatic biliary tree are an important cause of morbidity following hepatic surgery and trauma. Despite reduction in mortality for hepatic surgery in the last 2 decades, bile leaks rates have not changed significantly. In addition to posted operative bile leaks, leaks may occur following drainage of liver abscess and tumor ablation. Most bile leaks from the intrahepatic biliary tree are transient and managed conservatively by drainage alone or endoscopic biliary decompression. Selected cases may require reoperation and enteric drainage or liver resection for management.
Objectives. Endoscopic management of bile leak after orthotopic liver transplant (OLT) is widely accepted. Preliminary studies demonstrated encouraging results for covered self-expandable metal stents (CSEMS) in complex...Objectives. Endoscopic management of bile leak after orthotopic liver transplant (OLT) is widely accepted. Preliminary studies demonstrated encouraging results for covered self-expandable metal stents (CSEMS) in complex bile leaks. Methods. Thirty-one patients with post-OLT bile leaks underwent endoscopic temporary placement of CSEMS (3 partially CSEMS , 18 fully CSEMS with fins and 10 fully CSEMS with flare ends) between December 2003 and December 2010. Long-term clinical success and safety were evaluated. Results. Median stent indwelling and follow-up were 89 and 1,353 days for PCSEMS, 102 and 849 for FCSEMS with fins and 98 and 203 for FCSEMS with flare ends. Clinical success was achieved in 100%, 77.8%, and 70%, respectively. Postplacement complications: cholangitis (1) and proximal migration (1), both in the FCSEMS with fins. Postremoval complications were biliary strictures requiring drainage: PCSEMS (1), FCSEMS with fins (6) and with flare ends (1). There was no significant differences in the FCSEMS groups regarding clinical success, age, gender, leak location, previous treatment, stent indwelling, and complications. Conclusion. Temporary placement of CSEMS is effective to treat post-OLT biliary leaks. However, a high number of post removal biliary strictures occurred especially in the FCSEMS with fins. CSEMS cannot be recommended in this patient population.
Objective. Although several therapeutic strategies have proven to be effective for hydatid cyst of liver, but surgery is still the most common therapy despite its morbidity and mortality. Furthermore, a variety of techni...Objective. Although several therapeutic strategies have proven to be effective for hydatid cyst of liver, but surgery is still the most common therapy despite its morbidity and mortality. Furthermore, a variety of technique has been recommended for managing the residual cavity after cystectomy. We report here a new technical method for the reconstruction of hydatid cyst residual cavity with using overlapping flaps of liver edges (Vest over Pant). Methods. In this technique after removing the cyst, the edges of one side of cyst cavity were sutured to the base of the cavity using three to four mattress sutures), and edges of other side of liver was overlapped on the dorsal part of previous layer using four to five mattress sutures. Therefore residual cavity dead space was obliterated with two surfaces of cavity. Results. Fifty males were treated by our method. The average cyst volume was 423 ± 110 mL. There was no intraabdominal sepsis, bile leakage, or hepatic necrosis. In follow-up ultrasound study, residual cavities were disappeared one month after operation. Conclusion. Overlapping flaps of liver edges (Vest over Pant) provides easy, safe closure of cyst with preservation of the liver anatomy.
We assess whether the White test is better than the conventional bile leakage test for the intraoperative detection of bile leakage in hepatectomized patients. This study included 30 patients who received elective liver...We assess whether the White test is better than the conventional bile leakage test for the intraoperative detection of bile leakage in hepatectomized patients. This study included 30 patients who received elective liver resection. Both the conventional bile leakage test (injecting an isotonic sodium chloride solution through the cystic duct) and the White test (injecting a fat emulsion solution through the cystic duct) were carried out in the same patients. The detection of bile leakage was compared between the conventional method and the White test. A bile leak was demonstrated in 8 patients (26.7%) by the conventional method and in 19 patients (63.3%) by the White test. In addition, the White test detected a significantly higher number of bile leakage sites compared with the conventional method (Wilcoxon signed-rank test; P < 0.001). The White test is better than the conventional test for the intraoperative detection of bile leakage. Based on our study, we recommend that surgeons investigating bile leakage sites during liver resections should use the White test instead of the conventional bile leakage test.
Backgrounds. Pyogenic liver abscess is a rare disease whose management has shifted toward greater use of percutaneous drainage. Surgery still plays a role in treatment, but its indications are not clear. Method. We condu...Backgrounds. Pyogenic liver abscess is a rare disease whose management has shifted toward greater use of percutaneous drainage. Surgery still plays a role in treatment, but its indications are not clear. Method. We conducted a retrospective study of pyogenic abscess cases admitted to our university hospital between 1999 and 2010 and assessed the factors potentially associated with surgical treatment versus medical treatment alone. Results. In total, 103 liver abscess patients were treated at our center. The mortality was 9%. The main symptoms were fever and abdominal pain. All of the patients had CRP > 6 g/dL. Sixty-nine patients had a unique abscess. Seventeen patients were treated with antibiotics alone and 57 with percutaneous drainage and antibiotics. Twenty-seven patients who were treated with percutaneous techniques required surgery, and 29 patients initially received it. Eventually, 43 patients underwent abscess surgery. The factors associated with failed medical treatment were gas-forming abscess (P = 0.006) and septic shock at the initial presentation (P = 0.008). Conclusion. Medical and percutaneous treatment constitute the standard management of liver abscess cases. Surgery remains necessary after failure of the initial treatment but should also be considered as an early intervention for cases presenting with gas-forming abscesses and septic shock and when treatment of the underlying cause is immediately required.
Background. The aim of this study is to investigate the evidence of hypokalemia as a suitable parameter for therapeutic decision making after severe blunt liver trauma. Methods. We reviewed the medical records of 11 pati...Background. The aim of this study is to investigate the evidence of hypokalemia as a suitable parameter for therapeutic decision making after severe blunt liver trauma. Methods. We reviewed the medical records of 11 patients (9 M, 2 F, mean age 32 years) admitted to San Matteo Hospital of Pavia between 2007-2009. All of them were victims of road accidents hospitalized for blunt liver injury and submitted to surgery. Results. Hypokalemia was observed in 7/11 (63.6%) patients during the preoperative period (mean value 2.91 mEq/L). Serum potassium concentration normalized in all patients at the 7th postoperative day only (P < 0.01). Conclusions. According to literature results, our study confirms that after blunt hepatic injury serum potassium levels may decrease significantly. Therefore, kalemia must be carefully monitored in order to establish appropriate treatment and avoid any complications.
Background. There is only limited evidence available to justify generalized clinical classification and treatment recommendations for iatrogenic bile duct lesions. Methods. Data of 93 patients with iatrogenic bile duct l...Background. There is only limited evidence available to justify generalized clinical classification and treatment recommendations for iatrogenic bile duct lesions. Methods. Data of 93 patients with iatrogenic bile duct lesions was evaluated retrospectively to analyse the variety of encountered lesions with the Hanover classification and its impact on surgical treatment and outcomes. Results. Bile duct lesions combined with vascular lesions were observed in 20 patients (21.5%). 18 of these patients were treated with additional partial hepatectomy while the majority were treated by hepaticojejunostomy alone (n = 54). Concomitant injury to the right hepatic artery resulted in additional right anatomical hemihepatectomy in 10 of 18 cases. 8 of 12 cases with type A lesions were treated with drainage alone or direct suture of the bile leak while 2 patients with a C2 lesion required a Whipple's procedure. Observed congruence between originally proposed lesion-type-specific treatment and actually performed treatment was 66-100% dependent on the category of lesion type. Hospital mortality was 3.2% (n = 3). Conclusions. The Hannover classification may be helpful to standardize the systematic description of iatrogenic bile duct lesions in order to establish evidence-based and lesion-type-specific treatment recommendations.
We investigate the effectiveness of buttressing the surgical stapler to reduce postoperative pancreatic fistulae in a porcine model. As a pilot study, pigs (n = 6) underwent laparoscopic distal pancreatectomy using a sta...We investigate the effectiveness of buttressing the surgical stapler to reduce postoperative pancreatic fistulae in a porcine model. As a pilot study, pigs (n = 6) underwent laparoscopic distal pancreatectomy using a standard stapler. Daily drain output and lipase were measured postoperative day 5 and 14. In a second study, pancreatic transection was performed to occlude the proximal and distal duct at the pancreatic neck using a standard stapler (n = 6), or stapler with bovine pericardial strip buttress (n = 6). Results. In pilot study, 3/6 animals had drain lipase greater than 3x serum on day 14. In the second series, drain volumes were not significantly different between buttressed and control groups on day 5 (55.3 ± 31.6 and 29.3 ± 14.2 cc, resp.), nor on day 14 (9.5 ± 4.2 cc and 2.5 ± 0.8 cc, resp., P = 0.13). Drain lipase was not statistically significant on day 5 (3,166 ± 1,433 and 6,063 ± 1,872 U/L, resp., P = 0.25) or day 14 (924 ± 541 and 360 ± 250 U/L). By definition, 3/6 developed pancreatic fistula; only one (control) demonstrating a contained collection arising from the staple line. Conclusion. Buttressed stapler failed to protect against pancreatic fistula in this rigorous surgical model.
Background. Biliobronchial fistula (BBF) is a rare complication in the natural history of liver hydatid disease by Echinococcus granulosus. We present a case of BBF after resection of a giant liver hydatid cyst in a 72-y...Background. Biliobronchial fistula (BBF) is a rare complication in the natural history of liver hydatid disease by Echinococcus granulosus. We present a case of BBF after resection of a giant liver hydatid cyst in a 72-year-old woman. Case Report. A total cystpericystectomy was done, leaving the left lateral section of the liver that was fixed to the diaphragm. Postoperatively, the patient developed obstructive jaundice. An ERCP showed an obstruction at the junction of the left biliary duct and the main biliary duct and contrast leak. At reoperation, the main duct was ischemic, likely due to torsion along its longitudinal axis. A hepatotomy was done at the hilar plate, and the biliary duct was dissected and anastomosed to a Roux-en-Y jejunal loop. She was discharged without complications. Five months later, the patient developed cholangitis and was successfully treated with antibiotics. However, she suffered repeated respiratory infections, and four months later she was admitted to the hospital with fever, cough, bilioptysis, and right lower lobe pneumonia. The diagnosis of BBF was confirmed with (99m)Tc Mebrofenin scintigraphy. At transhepatic cholangiography, bile duct dilation was seen, with a biliothoracic leak. She underwent dilatation of cholangiojejunostomy stricture with placement of an external-internal catheter. The catheter was removed 3.5 months later, and two years later the patient remains in very good condition. Conclusion. An indirect treatment of the BBF by percutaneous transhepatic dilation of the biliary stenosis avoided a more invasive treatment, with satisfactory outcome.
Purpose. The incidence of liver tumors is rising in USA. The purpose of this study was to evaluate liver oxido-reductive status in the presence of chronic liver disease and hepatocellular carcinoma (HCC). Methods. Glutat...Purpose. The incidence of liver tumors is rising in USA. The purpose of this study was to evaluate liver oxido-reductive status in the presence of chronic liver disease and hepatocellular carcinoma (HCC). Methods. Glutathione species and ophthalmate (OA) concentrations were measured by LC-MS in processed plasma and red blood cells (RBC) from infected Woodchuck with hepatitis virus (WHV). Blood samples were obtained from: (i) infected animals with tumors (WHV+/HCC+), (ii) infected animals without tumors (WHV+/HCC-) and (iii) healthy animals (WHC-/HCC-). Results. The concentration of reduced glutathione (GSH) and the ratio GSH/GSG were lower in plasma from WHV+/HCC+ animals when compared to WHV+/HCC- and WHV-/HCC- (P < 0.01). In contrast, the concentration of oxidized glutathione (GSSG) was found to be higher in plasma from WHV+/HCC+ animals when compared to WHV+/HCC- and WHV-/HCC- (P < 0.01). The Glutathione species and its ratio from the RBC compartment were similar among all groups. OA concentration in both plasma and RBC was significantly higher from WHV+/HCC+ when compared to WHV+/HCC- and WHV-/HCC- (P < 0.01). Conclusions. Disturbances of the glutathione redox buffer system and higher concentrations of OA were found in the WCV+/HCC+ animal model. The role of these compounds as biomarkers of early tumor development in patients with end stage liver disease remains to be determined.
Purpose. We present our experience in single incision laparoscopic cholecystectomy by using a grasper directly without using a trocar in five patients. Methods and Results. The technique involves the use of Karl Storz 27...Purpose. We present our experience in single incision laparoscopic cholecystectomy by using a grasper directly without using a trocar in five patients. Methods and Results. The technique involves the use of Karl Storz 27290F grasper in order to perform gallbladder retraction in single port cholecystectomy. The grasper was introduced directly into the skin through abdominal wall without using any trocar and used to mobilize gallbladder whenever needed during surgery without causing any perforation or leakage of the gallbladder. There were no intraoperative and postoperative complications in 5 patients with the advantages of shorter operation time and almost invisible postoperative skin scar formation. Conclusion. We claim that the use of this instrument in SILS surgery might be advantageous than the conventional placement of sutures for the gallbladder mobilization.
Purpose. The study was undertaken to evaluate a novel classification system developed to estimate financial cost of bile duct injury (BDI) and to aid in decision making for referral. Study Design. A retrospective review...Purpose. The study was undertaken to evaluate a novel classification system developed to estimate financial cost of bile duct injury (BDI) and to aid in decision making for referral. Study Design. A retrospective review of patients referred for BDI was performed. Grade I injuries involve the duct of Luschka or accessory right hepatic ducts, grade II includes all other biliary injuries, and grade III includes all vasculobiliary injuries. Groups were compared using standard statistical methods. Results. There were 14 grade I, 74 grade II, and 20 grade III injuries. There was a significant difference in the cost and mortality of grade I ($12,457, 0%), grade II ($46,481, 1.4%), and grade III ($69,368, 15%, P = 0.002 and P = 0.030, resp.) injuries. Grade II and III injuries were significantly more likely to require surgical repair (OR 27.7, P < 0.001). Conclusion. We have presented a simple classification system that is able to accurately predict cost and need for surgical repair.
Ectopic liver tissue is a rare clinical entity that is mostly asymptomatic and found incidentally. In certain situations, however, patients may present with symptoms of abdominal pain secondary to torsion, compression, o...Ectopic liver tissue is a rare clinical entity that is mostly asymptomatic and found incidentally. In certain situations, however, patients may present with symptoms of abdominal pain secondary to torsion, compression, obstruction of adjacent organs, or rupture secondary to malignant transformation. Herein, we report a case of a 25-year-old female that presented with acute onset of epigastric pain found to have ectopic liver tissue near the gallbladder complicated by acute hemorrhage necessitating operative intervention in the way of laparoscopic excision and cholecystectomy. The patient's postoperative course was uneventful. Gross pathology demonstrated a 1.2 × 2.8 × 4.5 cm firm purple ovoid structure that histologically revealed extensive hemorrhagic necrosis of benign ectopic liver tissue.
Many staging systems of hepatocellular carcinoma (HCC) were established; however, there is no consensus on which is proper in predicting prognosis. This study aims to evaluate various commonly used staging systems of HCC...Many staging systems of hepatocellular carcinoma (HCC) were established; however, there is no consensus on which is proper in predicting prognosis. This study aims to evaluate various commonly used staging systems of HCC. Patients who underwent surgery during 2001-2007 were included. All patient data were retrospectively staged using six staging systems, that are American Joint Committee on Cancer (AJCC) Tumour-Node-Metastasis (TNM), Okuda staging, Cancer of the Liver Italian Program (CLIP), Barcelona Clinic Liver Cancer (BCLC), Chinese University Prognostic Index (CUPI), and Japan Integrated Staging (JIS). Child-Pugh classification was also evaluated. The staging systems were compared by mean of overall and disease-free survival. Total of 99 patient data were enrolled in the analyses. All staging systems except Okuda were significant in determining overall survival in univariate analyses. In multivariate analyses, TNM and Child-Pugh demonstrated better predictive power for overall survival. In terms of disease-free survival, univariate analyses revealed that TNM, CLIP, BCLC, CUPI, and JIS were significant, and TNM was the best predictive staging system in multivariate analyses. In our study, TNM and Child-Pugh are the representative systems in predicting survival of HCC patients who undergo surgical resection. Moreover, they are practical and easily assessable in clinical practice.
Peutz-Jeghers syndrome is a rare autosomal dominant inherited disease characterized by a special type of hamartomatous gastrointestinal polyps combined with mucocutaneous melanin pigmentations. Patients with the syndrome...Peutz-Jeghers syndrome is a rare autosomal dominant inherited disease characterized by a special type of hamartomatous gastrointestinal polyps combined with mucocutaneous melanin pigmentations. Patients with the syndrome have a high risk of developing neoplasia, with colon, small bowel, and stomach being the most common gastrointestinal sites. Herein, we present the occurrence of a rare tumor in patients with Peutz-Jeghers syndrome; a cholangiocarcinoma of the endopancreatic bile duct. A minireview is also presented. It can be concluded that cholangiocarcinoma remains a possible diagnosis in PJS patients, as in others that present with biliary obstruction. PJS patients may be at higher risk than others in view of their propensity for malignancy.
We report a rare case of a laparoscopic splenectomy performed for a carcinoid metastasis. The patient represented with pleuritic left-sided chest pain from pleural deposits 9 years following resection of a primary lung c...We report a rare case of a laparoscopic splenectomy performed for a carcinoid metastasis. The patient represented with pleuritic left-sided chest pain from pleural deposits 9 years following resection of a primary lung carcinoid tumour. They were found to have a 4.7 cm splenic lesion on CT with a probable left acetabular metastasis demonstrated on Gallium PET scan. The patient underwent laparoscopic splenectomy for debulking treatment of the splenic lesion that was confirmed to be a splenic metastasis of the resected carcinoid lung tumour. Following an uncomplicated recovery, the patient was discharged on the second postoperative day. On discharge, she received adjuvant therapy with Lutetium 177 DOTATATE. This is the first report of a carcinoid splenic metastasis successfully treated with laparoscopic splenectomy.